Male urological disease Flashcards
Causes and Medical conditions associated with erectile dysfunction? (formative Q)
- Age
- Neuropathic causes (diabetes, alcohol excess, multiple sclerosis)
- Vascular insufficient (atheroma, Coronary Artery disease)
- Dyslipidaemia
- Hypogonadism
- Trauma
- Drugs (b-blockers, thiazide diuretics)
- Psychosomatic (stress, anxiety)
Medical Conditions associated with it: • Diabetes mellitus • CVD: MI, HTN • Liver disease and alcohol • Renal failure • Trauma - Pelvic fracture • Iatrogenic - Prostatectomy 75%
1st line and alternative Tx and Mx for erectile dysfunction
- PDE-5i (1st line) - sildenafil, tadalafil
- Other Tx (2nd line)
- Intraurethral suppository
- Intracavernosal injection
- Vacuum assisted device
- Shockwave therapy - Psychotherapy is psychological problems are present
How does PDE-5i work? what are its SE and CI?
(1. ) Elevates cGMP levels in vascular smooth muscle cells of the corpus cavernosum
(2. ) Causes vasodilation, inc blood flow, penile erection
(3. ) Inform pt about a sustaining erection (priapism) that may occur for more than 4hrs, and if get pain to go visit specialist.
(4. ) CI = If taking GTN as causes severe hypotension
What is prostatitis? Clinical Features? Ix? Tx?
(1.) Common urological dx in men <50y. Inflammation of prostate. Bacterial prostatitis = caused by infection/UTI (e.coli common).
(2. ) Sx:
- abdo, perianal, groin pain
- painful ejaculation
- acute onset of LUTs (frequency, dysuria, difficulty passing, poor stream).
- systemic sx: fever, chills, malaise
(3. ) Ix
- Urinalysis
- Urine, blood, semen culture
(4. ) Tx:
- Bacterial = 4-6w Abx, Quinolone
What is BPH? Patho? RF?
(1. ) Very common in men over 50y.
(2. ) BPH/BPE arises from smooth muscle hyperplasia of transitional zone
(3. ) This compresses urethra and causes BOO so we see LUTS (voiding and storage sx) associated with BOO
(4. ) It does NOT inc risk of prostatic cancer.
(4. ) RF = >50y, Fx, non-asian, smoking
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3 Clinical features of BPE
(1. ) LUTS
(a. ) Voiding Sx: weak stream, dribble, dysuria, straining
(b. ) Storage Sx: frequency, urgency, nocturia, and incontinence
(2.)AUR: as unable to micturate, develop painful & distended bladder
(3. ) Following may also be present:
- Haematuria
- Bladder stones
- UTI, fever?
BPE Ex (5.)
**(1.) DRE: BPH is smooth enlarged prostate
**(2.) Genitals + Abdo Ex: palpable bladder?
**(3.) Neurological Ex: Is SC injury causing LUTs?
(4.) IPSS Questionnaire: Severity of Sx? Allows to monitor improvement, deterioration and QoL
(5) Flow-volume chart
- Filled by pt
- Monitor quantity, time and any incontinence
Ix of BPE (3)
Dx = BOO secondary of BPE, LUTS
(1. ) Urinalysis
- detect infection (leukocytes, nitrates)
- NVH
- glycosuria (metabolic problem?)
- Abnormal dipsticks require further tests e.g. cultures
(2. ) PSA
- implications should be discussed prior
- if +ve + DRE is +ve -> TRUS + biopsy
(3.) IPSS questionnarie
Consider
- US
- CT abdomen/pelvis
- Uroflowmetry studies
- Cystoscopy: if red flag sx, infection, stones, haematuria,
PSA - what is it? what must be considered? pros and cons?
(1. ) Prostatic Specific antigen is part of normal male physiology - its role is to liquify semen.
(2. ) Levels raised in = large prostate, infection, catheterization, prostate cancer, ejaculation
(3. ) Used with caution and should not be done routinely in Ix of BPH. PSA may be indicated where cancer is suspected (malignant feeling prostate, metastatic disease suspected)
(4. ) Informed Consent Testing, benefits and risks of PSA testing are explained
Tx of BPE (4)
(1.) WW and lifestyle advice: if Sx do not bother pt. Weight loss, reduce caffeine
(2. ) Medical interventions:
(a. ) 1st line: a-blocker (tamsulosin)
- prostate <30g, relaxes smooth muscle
(b. ) 5alpha-reductase inhibitor (finasteride)
- Inhibits testosterone to dihydrotestosterone
- reduces prostate size
(c. ) Combination may be used
(3.) AUR requires immediate catheterisation + urgent Tx
(4. ) Surgery: TURP
- If Tx fails, complications such as AKI, stones, haematuria
Aetiology, Sx, Tx of Acute Urinary Retention
(1. ) AUR is SUDDEN inability to pass urine.
(2. ) Aetiology = BPE, bladder stones
(3. ) Sx = unable to micturate, lower abdo or flank pain, swelling of bladder
(4. ) Tx = Catheter will relieve pressure on bladder and abdo
Complications of BPE
- Urinary retention
- Chronic retention
- UTI (due to incomplete emptying)
- Haematuria
- Bladder calculi
- Sexual dysfunction: On alpha blocker and 5-alpha reductase inhibitor
3 RF of Prostate Cancer?
- Most common malignancy in men.
- RF = Age (~70y), Fx, black ethnicity
- Although there is a small trend, Fx as a RF is weak
Where does the cancer arise in prostate cancer? where can it metastasise? prognosis?
(1. ) It is an adenocarcinoma that occurs in the peripheral zone
(2. ) Metastatic spread:
- pelvic lymph nodes
- bone metastases (lumbar spine and pelvis)
- Lung, liver, brain (rare)
(3. ) 10-year survival rate from 95% to 10% (metastatic)
Clinical features of prostate cancer
- Asymptomatic
- LUTS are rare, more common in BPE
- If metastases present: Back pain, weight loss, anaemia, obstruction of ureters
Examination and Investigations of prostate cancer (5.)
(1. ) DRE
- Nodular, hard
- H/e in 45% tumour is not palpable
(2.) PSA level
Consider below…..
(3. ) Transrectal US + biopsy
- If abnormal DRE + PSA levels
- Gleason’s grading assess histology and aggressiveness
(4. ) Pelvic MRI, CT
- Once Dx is confirmed
- Can be used to confirm staging and involvement
(5. ) Bone scan
- If metastases is suspected, high PSA may indicate this
Mx and Tx of Prostate Cancer (5)
(1.) Low grade = WW + Surveillance (PSA, DRE, biopsy)
(2. ) Intermediate Risk = Radial prostectomy or radical radiotherapy w/ anti-androgen drugs for 6m
- localised tumour and pt w/>10y life expectancy for surgery
(3.) High Risk = Radial prostectomy or radical radiotherapy w/ anti-androgen drugs for 3y
(4. ) Chemotherapy
- If fails to respond to endocrine Tx or disease improves & then comes back
(5.) Analgesic for bone pain
RF for testicular cancer (8.)
- 20-40y men
- Cryptorchidism (undescended testes)
- infant hernia
- infertility
- white Caucasians
- Fx
- HIV
- Genetics: TGCT1 mutation
What is testicular cancer and where does it arise from?
(1. ) Most common malignancy in young adult men + curable when diagnosed early.
(2. ) Hard, painless nodule on one testis
(3. ) Elevated serum markers aid dx and monitoring tx response: alpha-fetoprotein (AFP), beta-human chronic gonadotrophin (B-hCG)
(4. ) >95% of arise from germ cells: seminoma & teratoma. The remaining arise form leydig cells - usually small and benign, secretes oestrogen thus presents with gynaecomastia
Staging of testicular cancer
- No metastases, no evidence of disease outside the testis
- Infradiaphragamatic node involvement (via para-aortic nodes)
- Supradiaphragmatic node involvement
- Lung, liver involvement
Clinical features of testicular cancer (5.)
- > RF present: young, mass, fx, cryptorchidism
(1. ) Hard painless lump
(2. ) Testicular +/- abdo pain
(3. ) Dragging sensation
(4. ) Gynaecomastia (leydig tumor)
(5. ) Look for involvement:
(a. ) Lymph involvement?
- Para-aortic nodes = back pain
- Abdominal mass/lump
(b. ) Metastases
- liver, lung, bone and brain.
- lung metastases = dyspnoea
Investigations of testicular cancer (5.)
(1. ) 2ww referral - can be done following or prior to USS
(2. ) Scrotal US and doppler: confirms Dx
(3. ) CXR, CT or pelvis abdo: staging
(4. ) Serum tumour markers (beta-hCG, AFP)
(5. ) Inguinal orchiectomy
- confirm histological diagnosis is initial treatment in most cases.
Management of testicular cancer
(1. ) Radical orchidectomy (complication: infertility)
(2. ) Chemotherapy if metastases
(3. ) Encourage self-examination
(4. ) Follow up: CT, assess AFP, b-hCG
